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N332 > Palliation + Symptom Management at EOL > Flashcards

Palliation + Symptom Management at EOL Flashcards

1
Q

T/F Regardless of illness, many at EOL exprerience similar symptoms

A

T

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2
Q

What is considered a “cornerstone” of EOL care? Why?

A

Anticipating + planning interventiosn for symptoms that have not yet occurred is cornerstole of EOL care.

Family + pt will tolerate better if know what’s coming and how to manage it

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3
Q

What is the purpose of an “emergency kit” for EOL patients?

A

• Pt may be given “emergency kit” of meds to take at prescribed doses to avoid prolonged suffering and/or rehospitalization
–> can take as needed and as things progress w/o needed to seek medical team

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4
Q

At end of life, should a patient’s established regimen for pain management be interrupted?

A

Nope, continue it! (I assume may need to be upped in many cases)

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5
Q

Considerations for route of pain meds at EOL?

What is one good route for those having difficulty swallowing?

A
  • Pts at EOL may not be able to do oral d/t comnolence or nausea – use other routes
  • Concentrated Morphine solution sublingually is effective for intermittent analgesic (good if pt can’t swallow)
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6
Q

_____ regimen needed if taking opioids

A

Bowel care

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7
Q

How does timing around dying occur in relation to medication dose admin?

  • implications for family around this?
A

• Strong possibility that pt will die right around time of dose…family needs to know this so doesn’t think caused it by giving med

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8
Q

T/F Dysnpea always correlates with a change in Spo2 status

A

F - May not correlate w resp rate or O2 sat

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9
Q

How is dypnea a self-perpetuating cycle?

What needs to be taught around this?

A

Causes anxiety…which causes more dyspnea

  • Anxiety + dyspnea exacerbate each other and can lead to respiratory crisis – should be taught how to manage this and have emergency plan
  • Need to reassure dyspnea can be managed at home w/o need for emerg medical services hospitalization and that support is available
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10
Q

Is it likely that all measures will be taken to address the route cause of dyspnea at EOL? How is this balanced?

A

• Benefits of treating underlying cause at EOL may not be worth their risks (ex: blood transfusion may be short lived alleviation for pt with anemia)

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11
Q

Nursing management of dyspnea.

A
  • Treat underlying pathology
  • Dec anxiety
  • Altering perception of breathlessness
  • Reduce resp demand
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12
Q

Measures for nurses to treat the underlying patho treated for dysnpea?

A

bronchodilators + corticosteroids, blood products, erythropoietin, diuretics + monitor fluid balance

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13
Q

how to dec anxiety in EOL pt?

A

anxiolytics, relaxation techniques + guided imagery, provide pt with means to call for assistance (CB in reach)

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14
Q

How to alter perception of breathlessness in EOL pt?

A

O2, morphine or opioids, use fan to provide air movement in room

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15
Q

How to reduce resp demand in pts at EOL?

A

teach energy conservation measures, place everything w/in reach, use commode

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16
Q

What might need to be considered for pt who fears sensation of suffocation at EOL?

A

Palliative sedation

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17
Q

What can be used to track fatigue at EOL?

A

Can use standardized scale

such as visual analog scale for tiredness

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18
Q

Is fatigue at EOL always a bad thing?

A

• At EOL, may provide protection from suffering so not always detrimental

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19
Q

How does nutritional need and processing change at EOL?

A
  • Desires for food + fluid may diminish
  • May not be able to store or utilize nutrients effectively anymore
  • Not unusual for seriously ill to develop eversions to food they loved before, have no apetite at all
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20
Q

How can inc anorexia in dying person affect family?

A

• Is social activity – can become battleground of well meaning family members trying to get ill person to eat

  • family wants to feed them but need to know this is normal part of EOL process
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21
Q

Cachexia =

A

muscle wasting and weight loss assoc with end stage illness

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22
Q

T/F

Anorexia the primary cause of cachexia at EOL

A

F - Anorexia may contriute to cachexia but not primary cause – assoc w changes in metb (hypercatabolism) that leads to loss of protein stores.

23
Q

Do we know the cause of cachexia at EOL?

Does it resolve if you get the patient to eat more?

A

• Patho of cachexia in terminal illness not entirely understood.

Severity of tissue wasting > reduced intake alone + does not resolve with food intake.

Assoc w cytokines + inflm mediators.

24
Q

How are anorexia + cachexia different from starvation?

A

• Anorexia + cachexia different from starvation. Body mass is alleviated in starvation by nutritional supplementation (anorexia + cachexia not)

25
Q

What sorts of pharmacological interventions help w anorexia?

A
  • Corticosteroids may improve appetite – have short term benefit ~3wks – improve intake and quality of life
  • Progestational agents may stimulate appetite but won’t inc QOL. Risk thromboemolitic events + other AEs.
  • Promotility agents (metoclopramide or domperidone) inc GI molity, dec early satiety
26
Q

Should nutritional supplementation be done at EOL?

Is starvation a bad thing at EOL? Does it cause great suffering?

A

• Nutritional supplementation done in early stages and chronic disease but important not to understand starvation may not be causing suffering and hastening death. Starvation should not be viewed as failure to implant tubes for nutritional supplementation – will not necessarily prolong life anyway.

27
Q

In pts close to death, are benefits to withholding lots of fluids/food. What are they?

A

• dec urine output + incontinence, dec gastric fluids + emesis, dec pulm secretions + resp distress, dec edema + pressure discomfort

28
Q

How to guide family who wants to feed their anorexic dying family member?

A

• As approaches EOL, want to offer pt that they desire + can easily tolerate.
Family’s need to be taught to show love + caring in other ways.

29
Q

• Can promote nutrition for terminally ill by:

A
  • Offer small portions of favorite foods
  • Don’t focus on “balanced” diet
  • Cool foods may be better than hot
  • Off cheese, eggs, PB, mild fish, chicken or tukey. Beef may taste bitter + unpleasant
  • Add milkshakes, liquid supplements
  • Add dry milk poweder to milkshakes + cream soups to inc protein + caloric intake
  • Schedule meals to have w family
  • Avoid arguments at mealtime
  • Assist pt to maintain oral care. Rinse mouth after each meal or snack. Avoid EtOH mouthwashes. Soft toothbush, tx mouth ulcers. Ensure dentures fit well
  • Tx pain + other symptoms
  • Offer ice chips made from frozen fruit juices
  • Allow pt to refuse food
30
Q

How does delirium r/t end of life?

A

• In some, prolonged period of delirium may occur before death

31
Q

How is delirium similar to depression + dementia and how does it differ from each of these?

A
  • Can have similarities in symptoms with depression + dementia and may occur concurrently
  • Dementia not assoc w change in LOC, whereas LOC fluctuates w delirium
  • Depression also has altered thoughts + concentration but they occur w clustered of other symptoms
32
Q

Risks for delirium =

A

• infect, metabolic/endocrine imbalances, hypoxemia, toxins, tumours, mets, CNS alterations (incl meds + sleep deprivation)

33
Q

T/F Delirius people are hyperactive

A

Kinda true…kinda false…

Can become hypoactive, hyperactive or both

34
Q

What can be done for patients who remain delirium despite treating underlying cuse?

A

• Hydration + pharmacologic intervention may help those who don’t get relief from treating underlying cause

35
Q

Which meds might be used for delrium?

A
  • Low do haloperidol (Haldol) may reduce hallucinations + agitation
  • Ativan may reduce anxiety but not clear the sensorium + may worsen cog impairment if used alone
36
Q

Nursing management for dleirium

A
  • Early recognition + prevention
  • ID underlying case
  • Deal w family distress. Teach them how to interact w patient
  • Ensuring safety of pt + family
  • Monitoring effects of meds
  • Confusion may mask pt’s unmet spiritual needs + fear of death – can use musical therapy, therapeutic touch, gentle massage
  • Reduce enviro stumuli
  • Promote sleep-wake cycles
  • Provide gentle reorientation
37
Q

T/F Depression is expected and accepted at EOL

What should you not confuse it with?

A

• Clinical depression should not be accepted as inevitable consequence of dying

don’t confuse it with anticipatory sadness + grieving

38
Q

CA patients w advanced disease at risk for

A

delirium, depression, suicidal ideation and severe anxiety

39
Q

What sort of pharmacologic interventions may be used for pt with depression at EOL?

A

psychostimulants, SSRI + tricycle antidepressants

40
Q

T/F Most patients should be able to be relieved of their symptoms at EOL?

What can be offered to those who can’t get relief?

A

True but…. Some pts experience distressing intractable symptoms

Those w unrelieved symptoms can be offered continuous palliative sedation therapy near EOL

41
Q

Is the intention of palliative sedation to hasten death?

A

• Intent to palliate symptoms, not hasten death

42
Q

When is palliative sedation most often used?

A
  • Most often used when pt experiences dyspnea, agitated delirium, or catastrophic terminal events (massive hem or uncontrolled seizures)
  • Typically used if pt is to die within 1-2wks (usually a few hours to days)
43
Q

What must be in place for patient who is going to recieve palliative sedation?

A

DNR order

44
Q

How is palliative sedation done?

A

• Done through continuous IV or subcut infusion of benzos or antiphotic in doses adequate to induce deep sleep.

45
Q

Are analgesics continued with palliative sedation?

A

YES! Still needed for pain management

46
Q

Important things to do around palliative sedation?

A

discuss w pt or proxy named in advance directive, discuss rationale + document process of consent, give family time alone w pt before enters deep sleep, provide psych support for family

47
Q

Role of nurse in palliative sedation?

A

• Nurse provides psych support, facilitates clarification of values + preferences, initiates + titrates meds, comfort-based physical care

48
Q

What is an overall effective way to decrease anxiety around time of death?

A

prepare with what to expect (for both family + pt) so not so alarming as changes occur

• Family needs to be instructed on what to prepare for in moments before + after death

49
Q

Noisy gurgling breathing + moaning can be most distressing symptoms at EOL for family.

What is this due to?

A

Inc unable to clear sputum + oral sections more resp difficulty + dried secretions
- these resp sounds d/t oropharyngeal relaxation + diminished awareness…
Moaning d/t air pushing past relaxed vocal cords.

50
Q

What to do to maintain mucous membranes in dying pt?

A

Gentle mouth care w very soft toothbrush

51
Q

Is deep suctioning appropriate for dying pt?

A

No, often causes suffering

52
Q

What to do for patient + family with respiratory changes?

A

• Oral suctioning, positioning to enhance drainage + sublingual or transdermal admin of anticholergic drugs to reduce secretions

family reassurance needed (tell them suctioning not necessarily helpful) –> need to be reassured these noises don’t indicate distress

53
Q

Signs of Approaching Death

A
  • Less interest in eating + dresinking
  • Urine output dec
  • Pt sleeps more and begins to detach from environment – let them sleep.
  • Mental confusion apparent as less O2 available for brain (may have strange dreams or visions) – may need to gently reorientate
  • Vision + hearing may be impaired + speech difficult to understand – speak clearly but not loudly, keep lights on as pt asks, keep talking as if can hear (hearing may be last to go)
  • Secretions collect in back of throat. May cough, mouth may become dry + crusty – use mouth swabs, offer sips H2O
  • Breathing may be irregular w periods of apnea. Moaning occurs as air passes by relaxed vocal cords (not necessarily sign of distress) – raising HOB may help
  • O2 deprivation leads to restlessness, hallucinations
  • Loses ability to control temp – provide blankets (not electric as may cause burn)
  • May become incontinent
  • May see gardens, libraries, or friends + family that have died. May want to “go” and ask for passport or start doing chores – assure can “go” without leaving bed, stay close, be present

N332 (8 decks)

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